Characteristics and risk factors of acute dystonia in schizophrenic patients treated with nemonapride, a selective dopamine antagonist

Upcoming agents for the treatment of schizophrenia: mechanism of action, efficacy and tolerability

Since the introduction of a group of atypical antipsychotics in the 1990s, there has been a decline in the rate of new antipsychotics being introduced into clinical practice. However, with increasing safety and efficacy concerns over currently available drugs and a dearth of options available for atypical depot formulations, there is a considerable need for the development of new formulations and agents. This review examines the profile of seven antipsychotic drugs currently in the premarketing stage of development and summarizes their mechanism of action, clinical potential and safety.Asenapine is an antipsychotic with activity for multiple receptors and has potential to improve negative and cognitive symptoms of schizophrenia. Bifeprunox is a partial dopamine D2 and serotonin 5-HT(1A) receptor agonist showing a less than convincing efficacy profile, but which may offer safety advantages over available agents by means of a reduced risk of metabolic complications. Iloperidone is a D2 and 5-HT(2A) receptor antagonist requiring further studies to establish its effectiveness. It has a high affinity for alpha(1)-adrenoceptors, which can lead to associated haemodynamic adverse effects. Nemonapride is essentially a typical antipsychotic drug, similar in structure to sulpiride, which has been available for some time in Japan. It has efficacy against positive symptoms and has shown some antidepressant and anxiolytic properties, although efficacy data for it are somewhat limited. Norclozapine (N-desmethylclozapine) is a major metabolite of clozapine formed by its demethylation. Its partial agonist activity at D2 receptors has raised interest in it as an antipsychotic in its own right. In addition, it appears to have muscarinic agonist activity, which is believed to be responsible for the observed positive effects it has on cognition. It was envisaged to be effective as an adjunct to other agents or at high doses in the treatment of refractory schizophrenia, although a recent randomized, controlled study showed that it was no more effective than placebo in patients with schizophrenia experiencing an acute psychotic episode. Olanzapine pamoate depot injection has shown comparable efficacy to oral olanzapine in several studies. However, it has provoked considerable safety concerns by its association with inadvertent intravascular injection events in numerous patients. This accidental intravascular administration of olanzapine pamoate leads to excessive sedation, confusion, dizziness and altered speech. Post-injection observation periods and postmarketing surveillance are planned following the introduction of the depot. Paliperidone palmitate is the palmitate ester of paliperidone, the major metabolite of risperidone, and is formulated as a long-acting injection for intramuscular use. Its pharmacology is comparable to risperidone, having D2 and 5-HT(2A) receptor antagonist activity. Efficacy studies have shown positive results, and because paliperidone has no antagonistic activity at cholinergic receptors, it has low potential for anticholinergic adverse effects, including cognitive dysfunction. However, with higher doses, the frequency of extrapyramidal side effects and orthostatic hypotension have been shown to be greater than with placebo.

Sigma1 and dopamine D2 receptor occupancy in the mouse brain after a single administration of haloperidol and two dopamine D2-like receptor ligands

We investigated sigma(1) and dopamine D(2) receptor occupancy in mouse brain after a single injection of haloperidol, nemonapride, or spiperone using [(11)C]SA4503 and [(11)C]raclopride, respectively. Co-injection of the three compounds significantly blocked the uptake of each radioligand. Six hours later, only haloperidol blocked [(11)C]SA4503 uptake, while all three reduced [(11)C]raclopride uptake. Sigma(1) receptor occupancy by haloperidol was reduced to 19% at day 2 when D(2) receptor occupancy disappeared. [(11)C]SA4503 would be applicable to the investigation of sigma(1) receptor occupancy of antispychotic drugs using PET.

The characteristics of side-effects of bromperidol in schizophrenic patients

The characteristics of the side-effects of bromperidol was investigated in 33 acutely exacerbated schizophrenic patients. The most frequently observed side-effects were extrapyramidal symptoms. Acute dystonia developed in 10 of 33 patients, and the mean age was significantly lower (P < 0.05) in patients with dystonia (27.3 +/- 6.2 years) than that in patients without dystonia (41.5 +/- 12.9 years). Plasma drug concentrations were not associated with side-effects. These findings suggest that acute dystonia is affected by age factor, and that daily dosage or monitoring of drug concentration is unlikely to be a useful marker for the prediction of side-effects during bromperidol treatment.

Associations between side effects of nemonapride and plasma concentrations of the drug and prolactin

Associations between neuroleptic side effects and plasma concentrations of the drug and prolactin were investigated in 33 acutely exacerbated schizophrenic patients (16 males and 17 females) treated with a fixed dose of nemonapride (18 mg/day), a new substituted benzamide, for 3 weeks. The most frequently observed side effects during nemonapride treatment were extrapyramidal symptoms such as akathisia (69.7%), dystonia (48.5%), hypokinesia (45.5%), tremor (39.4%) and increased salivation (36.4%). There were positive correlations between prolactin response and extrapyramidal side effects (EPS) scores after 1 week (Spearman rank correlation rs=.651, P<.01), 2 weeks (rs=.567, P<.05) and 3 weeks (rs=.670, P<.01) in male patients although no significant correlations were found in female or total patients. No significant correlations were found between plasma concentrations of the drug and total or any subscale side effects scores. The present study thus suggests that the spectrum of nemonapride-induced side effects is characterized by predominant extrapyramidal symptoms, and that prolactin response as an index of dopamine blockade reflects severity of EPS at least in male patients treated with nemonapride.

No relationship between--141C Ins/Del polymorphism in the promoter region of dopamine D2 receptor and extrapyramidal adverse effects of selective dopamine D2 antagonists in schizophrenic patients: a preliminary study

Previous studies have shown that subjects without Del alleles of the--141C Ins/Del polymorphism in the promoter region of the dopamine D2 receptor (DRD2) gene have lower DRD2 density that those with one or two Del alleles. The present study aims to investigate the relationship between the -141C Ins/Del polymorphism and extrapyramidal adverse effects of bromperidol and nemonapride, antipsychotic drugs with a selective and potent DRD2 antagonistic property, in schizophrenic inpatients. Twenty-seven patients were treated with bromperidol at a fixed-dose of 6, 12 or 18 mg/day, and 25 patients were treated with nemonapride at a fixed-dose of 18 mg/day. The duration of treatment with these drugs was 3 weeks. The Ins and Del alleles were determined by PCR. Extrapyramidal adverse effects were assessed by the Udvalg for Kliniske Undersøgelser side effects rating scale. The subjects consisted of 38 homozygotes of the Ins allele and 14 heterozygotes of the Ins and Del alleles. There were no significant differences in the incidence or severity of extrapyramidal adverse effects between patients with and without the Del allele. It is possible that this result was due to a lack of statistical power. However, the present study suggests that the--141C Ins/Del polymorphism is not related to the development of extrapyramidal adverse effects during acute-phase treatment with antidopaminergic agents.

Effects of WAY 100635 on antipsychotic-induced catalepsy in 5-HT depleted animals: a role for tonic activation of 5-HT(1A) receptors

We recently observed that the 5-hydroxytryptamine (5-HT)(1A) receptor antagonist N-[2-[4-(2-methoxyphenyl)-1-piperazinyl]ethyl]-N-(2-pyridinyl)-cycloh exanecarboxamide (WAY 100635) enhanced antipsychotic-induced catalepsy, which we hypothesized to be due to a blockade of tonic 5-HT(1A) receptor activation. Here, we examined this hypothesis by studying the effects of WAY 100635 in animals that were depleted of 5-HT by repeated treatment with the 5-HT synthesis inhibitor p-chlorophenylalanine methyl ester. Depletion of 5-HT abolished the enhancement by WAY 100635 of catalepsy induced by low doses of the antipsychotics nemonapride and raclopride, in agreement with the hypothesis that WAY 100635 enhances catalepsy by blocking tonic 5-HT(1A) receptor activation. Given the predictive validity of catalepsy, these findings indicate that 5-HT(1A) receptor blockade may enhance the extrapyramidal side-effects of antipsychotics in humans.